| disease | Spinal Tuberculosis Complicated by Sinus |
Spinal subcutaneous node with sinus is one of the severe and common complications of spinal subcutaneous nodes. Before the advent of anti-subcutaneous node drugs, the incidence rate was 18. The longer the sinus, the shorter the life expectancy, with a mortality rate as high as 34% at that time. After the introduction of anti-subcutaneous node drugs, especially rifampin and others, the incidence rate significantly decreased. From 1954 to 1985, our department treated 2,772 cases of spinal subcutaneous nodes, among which 317 cases (11.4%) were complicated by sinus. The incidence rate declined from 21.9% in the 1950s to 7.2% in the 1980s. Males were slightly more affected than females, with ages ranging from 1.5 to 75 years, predominantly between 20 and 40 years (78.9%). The disease duration varied from one month to 30 years, with an average of 1 year and 7 months.
bubble_chart Pathogen
Causes of sinus formation: Spontaneous rupture of superficial abscesses accounted for 45.7%, while 73 cases (22.3%) developed sinus postoperatively, indicating inappropriate timing of surgery, possibly when the lesion was still in the exudative or sexually transmitted disease phase.
Bacteriological examination revealed secondary infection in 70% of cases, with the vast majority (83%) being Staphylococcus aureus infections, and a minority involving large intestine bacilli and Pseudomonas aeruginosa. This is the reason for the difficulty in treatment, poor efficacy, and disease recurrence (8.8%).
bubble_chart Clinical Manifestations
Spinal subcutaneous nodules are predominantly found in the thoracolumbar, lumbar, and lumbosacral regions. Sinuses are commonly seen in the iliac fossa, accounting for 26.6%, followed by the superior lumbar triangle (17.6%). Symptoms often manifest as those of spinal subcutaneous nodules.
bubble_chart DiagnosisIn 25% of cases, sinus secretions and subcutaneous node bacterial cultures are positive, which can be considered as one of the Bingchuan infection sources. Diagnosis is not difficult when combined with bacteriological examination.
bubble_chart Treatment Measures
Treatment Methods: Comprehensive treatment including anti-subcutaneous node therapy, anti-infection, sinus drainage, and/or surgery is adopted.
1. Indications and Timing for Surgery
After 3-4 months of rational chemotherapy, if the sinus remains unhealed, surgery may be considered under the following conditions: ① Significant vertebral destruction with sequestra, caseous material, or multiple abscesses; ② Secondary infection of the sinus is controlled, with no systemic fever, minimal local pus, and 2-3 consecutive negative bacterial cultures; ③ The sinus is well-drained.
2. Preoperative Preparation
(1) Anti-subcutaneous node drugs: Develop a regimen using drugs effective against both subcutaneous node and mixed infections, such as rifampicin, ofloxacin, and ciprofloxacin. Combine medications for 2-3 months.
(2) Sinus imaging: Clarify the sinus's location, the size of its dead space, and its relationship with bone lesions and visceral organs to guide surgical planning.
(3) Ensure sinus drainage and control secondary infection: Preoperative sinus enlargement or sinus shortening to ensure drainage is a critical perioperative step. Avoid local irrigation to prevent superficial pyogenic bacteria from entering deeper lesions.
(4) Systemic supportive therapy to improve the patient's general condition and enhance resistance.
3. Key Surgical Points
(1) Approach selection: For thoracic lesions, an extrapleural approach is preferred; for lumbar or lumbosacral lesions, an extraperitoneal approach is chosen.
(3) Ensure complete hemostasis upon completion.
(4) Place closed drainage and use absorbable sutures.
(5) Perioperatively administer pyogenic-sensitive drugs for 4-6 weeks to prevent recurrence of latent pyogenic infections.
4. Positioning
Determined by the location of the bone lesion and sinus.
5. Anesthesia: General anesthesia.
6. Operative Steps
(1) Incision: Depends on the bone lesion's location (refer to relevant sections). The sinus should ideally have a separate incision, with excision of the sinus orifice skin and subcutaneous tissue, and curettage of the sinus wall. Pathological examination of these soft tissues shows subcutaneous node lesions in 80% of cases, which should be excised during surgery.
(2) Exposure of the lesion: Tissues or organs adjacent to the sinus wall (e.g., peritoneum, intestines, nerves, and blood vessels) are often densely adherent and should be carefully dissected to avoid injury. Thoroughly remove sequestra, caseous material, granulation tissue, and scar tissue from the bone lesion and sinus. Ensure complete hemostasis and irrigate copiously with saline or antibiotic solution. Use absorbable sutures to close the wound, minimizing dead space. If necessary, fill with a pedicled muscle flap. Place a silicone tube for negative-pressure drainage in the lesion and a rubber sheet for subcutaneous drainage to prevent infection and ensure surgical success.
7. Postoperative Management
(1) Continue anti-subcutaneous node therapy for about 1 year. Based on preoperative bacterial culture and drug sensitivity tests, administer anti-infection drugs for 4-6 weeks.
8. Sinus Prevention
Our data show that 70% of sinus cases result from spontaneous rupture, incision drainage, or postoperative residue. Proactive prevention includes: (1) Early diagnosis and rational treatment; (2) Prompt aspiration of pus when abscess tension is high, repeating if necessary; (3) Timely closed drainage for cold abscesses with impending skin rupture; (4) For enlarging cold abscesses with systemic fever and toxicity, initiate chemotherapy first and schedule surgery later to avoid postoperative sinus formation.
The condition is often severe, with an average of 3.1 affected vertebrae, and may be complicated by active pulmonary subcutaneous nodules, tuberculous meningitis, renal subcutaneous nodules, epididymal subcutaneous nodules, hip joint subcutaneous nodules, sacroiliac joint subcutaneous nodules, etc.
